Senior Social Work - Social Worker
ChristianaCare
Wilmington, DE

PRIMARY FUNCTION:

To work as a team member of an ambulatory complex care and assist with program development and decision making on merging service delivery and program access issues. To assist patients and families to identify health, social, emotional, and environmental needs and to connect them with available resources/ services through the provision of a full spectrum of longitudinal health and social work services.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Participates as a member of a team, focused on addressing and improving the behavioral, physical and mental health of a focused segment of the population. Merging all aspects of health into a longitudinal, sustainable solution for health self-management.

Understands and leverages multiple electronic systems including population health platform(s), electronic medical records, health information networks, state and federal agencies sites.

Provides information on social service programs and state and federal regulations specific to the specialty population.

Works with the patient, family, community, state and federal agencies, inpatient facilities and any other applicable resources, to formulate a plan for longitudinal support (whether related to a hospital admission, or in the community) and self-management of behavioral, physical and social health conditions. Gathers and assesses information regarding the patient's physical needs, mental status, family support system, financial resources, and available community and governmental resources. Employs assessment to develop a comprehensive case management plan that will address the needs identified. Determines specific objectives, goals, and measures that are designed to meet the client’s needs that have been identified through comprehensive assessment.

Provides information about resources and options available in the community and coordinates service delivery.

Interprets patient/family needs and provides information concerning the availability and limitations of resources.

Educates and addresses concerns with service delivery including service gaps and access issues. Links patient/ family with available community and government resources to meet their identified needs.  The social worker always assures the patient is given the choice regarding agencies and services. Assists the patient and family in all aspects of accessing resources including in-person accompaniment, assistance with forms, advocating with agencies on their behalf, working with other facilities on support planning.

When inpatient or in the emergency department, coordinates with members of the health care team to formulate a discharge plan that provides the patient services in the appropriate post-acute care setting.  The plan will be action- oriented and time-specific including collaboration with utilization management to manage length of stay. As part of the discharge plan development process, collaborates with other healthcare professionals in case review.

Screens all clients for their need and desire for social work services.  May screen and assist others in the family unit, as needed. Consults with medical providers, behavioral health providers, ancillary services, psychiatric facilities, hospital facilities, all pertinent social service providers, legal system and other partners as needed to identify and implement care systems for the client for needs as determined by assessment and client preference.

Participates in outpatient multidisciplinary case reviews, focused on patient panel and patients of other team members.

Provides factual information based on current knowledge of their specialty service, to provide psychosocial support and assist the patient/family in coping with their disease to improve their overall health care management.

Provides specific information on how to communicate with physicians and other medical, social service, legal or other staff to better utilize the resources and increase understanding of the process.

Establishes comprehensive care plans for those patients with longitudinal care needs in accordance with established clinical guidelines, standards, and pathways.  Organizes, secures, integrates and modifies the resources necessary to meet the goals stated in the plan.

The social worker will monitor patient care across the continuum through follow-up with patients, families, and community services.

Educates the community and the general public regarding various symptoms and consequences related to specific diseases, conditions and hospitalization. This information will also include specifics regarding methods of professional intervention and description of the process of social work intervention in a medical setting.

Represents patient/family by intervening, negotiating and promoting their concerns.  Problems requiring advocacy may include individual, race, or class inequities or inadequate and non-existent medical, behavioral health or community resources, i.e., primary care, medication access, substance use disorder treatment, housing, food security, transportation etc.

Functions as consultant/advisor to hospital administration, utilization review, public and private insurance programs, state and federal agencies, when longitudinal planning results in an “impasse situation occurs. Keeps administration informed of changes in community, state, and federal policies that impact on the length of stay.

Maintains pertinent and timely documentation in patient's medical charts and departmental records.

Accurately maintains required departmental statistical data.

Collects and maintains specific information required for performance improvement indicators and research projects. Utilizes the department Quality Service Plan to address service issues as needed.

Performs patient/family evaluations and histories.  Performs standardized social health assessment and recording of intervention. Provides psychosocial support through individual, group, or family counseling, as needs dictate. Continuously reviews service area for group support needs and opportunities.

Represents Christiana Care, when requested, through participation on community/state boards, committees, panels, court hearings, etc. and attends community meetings associated with their specialty team.

Attends regularly scheduled staff meetings, i.e., team, divisional, or center-wide.

Supports the departmental educational and staff development initiatives including supervision of undergraduate/ graduate students enrolled in an accredited school of social work, and community health workers.  As a field work supervisor, is responsible to Field Instructor/Liaison from the school of social work for evaluating student’s performance and teaches the basics of medical social work and available community resources. Attends regularly scheduled departmental in-service presentations regarding new resources and clinical techniques.

Demonstrates skills and knowledge necessary to provide care appropriate to neonatal, pediatric, maternity, adolescent, adult, and geriatric patients, including knowledge of growth and development, the ability to obtain and interpret information to identify patient needs, and to provide the care needed.                            

Performs assigned work safely, adhering to established departmental safety rules and practices.  Reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.

Performs other related duties as required.

DIRECTION/SUPERVISION OF OTHERS:

May supervise one graduate or undergraduate student at a given time.  May assist in supervision of community health worker staff.  Provides direction on social work issues to members of their specialty team in the absence of the Social Work Director.

EDUCATION AND EXPERIENCE REQUIREMENTS:

Licensed Master’s Social Worker (LMSW) from an accredited graduate school of Social Work required. Must be eligible for licensure in Delaware, Maryland, New Jersey, and Pennsylvania

Licensed Clinical Social Worker (LCSW) preferred.

Minimum of 2 years related work experience preferred.

Direct experience in care planning, insurance authorization and arranging community services for complex populations  

Case Management Certification through the Commission for Case Management (CCM) or obtained within 18 months of eligibility

SPECIAL REQUIREMENTS:

N/A

WORKING CONDITIONS:

Occasional contacts with patients who have a communicable disease or who may behave violently.

Limited and inconvenient office space.    Frequent travel between Christiana Care campuses, offices, and as required to clinical conferences or community agencies.

Work locations are on site, work from home or hybrid to be determined by Supervisor. Orientation is expected to be on site as well as monthly meetings and retreats as instructed by Manager.